summary of benefitsbenefitsm.filice.com/dominican/2020/hn_ppo_bensum.pdf · when you use an...

Summary of Benefits

PPO Insurance Plan GLO

PPO SB 3

93547

DELIVERING CHOICES When you need health care, it’s nice to have options. That’s why Health Net Life* offers a Preferred

Provider Organization (PPO) insurance plan (called "Health Net PPO") — an insurance plan that offers

you flexibility and choice. This SB answers basic questions about Health Net PPO. Please contact the

Customer Contact Center at the telephone number listed on the back cover and talk to one of our

friendly, knowledgeable representatives if you have additional questions.

If you have further questions, contact us:

By phone at 1-800-522-0088,

Or write to: Health Net Life Insurance Company

P.O. Box 9103

Van Nuys, CA 91409-9103

This insurance plan is underwritten by Health Net Life Insurance Company and administered by

Health Net of California, Inc. (Health Net).

This Summary of benefits (SB) is only a summary of your health insurance plan. The plan's

Certificate of Insurance (Certificate), which you will receive after you enroll, contains the exact

terms and conditions of your Health Net Life coverage. You should also consult the Health Net

PPO Group Insurance Policy (Policy) (issued to your employer) to determine governing

contractual provisions. It is important for you to carefully read this SB and the plan's Certificate

thoroughly once received, especially those sections that apply to those with special health care

needs. This SB includes a matrix of benefits in the section titled "Schedule of Benefits and

Coverage." In case of conflict, the Certificate will control. State mandated benefits may apply

depending upon your state of residence.

Table of contents

HOW THE INSURANCE PLAN WORKS ........................................................................ 3

SCHEDULE OF BENEFITS AND COVERAGE .............................................................. 4

LIMITS OF COVERAGE ............................................................................................... 14

BENEFITS AND COVERAGE ...................................................................................... 16

UTILIZATION MANAGEMENT ..................................................................................... 23

PAYMENT OF PREMIUMS AND CHARGES ............................................................... 23

RENEWING, CONTINUING OR ENDING COVERAGE ............................................... 27

IF YOU HAVE A DISAGREEMENT WITH OUR INSURANCE PLAN .......................... 29

ADDITIONAL INSURANCE PLAN BENEFIT INFORMATION ..................................... 30

PRESCRIPTION DRUG PROGRAM ............................................................................ 30

NONDISCRIMINATION NOTICE .................................................................................. 35

NOTICE OF LANGUAGE SERVICES .......................................................................... 36

PPO SB 3

How the Insurance Plan Works Please read the following information so you will know from whom or what group of providers health care

may be obtained.

SELECTION OF PHYSICIANS

This insurance plan allows you to:

Choose your own doctors and hospitals for all your health care needs; and

Take advantage of significant cost savings when you use doctors contracted with our PPO.

Like most PPO insurance plans, Health Net PPO offers two different ways to access care:

In-network, meaning you choose a doctor (or hospital) contracted with our PPO.

Out-of-network, meaning you choose a doctor (or hospital) not contracted with our PPO.

Your choice of doctors and hospitals may determine which services will be covered, as well as how much you

will pay. In many instances, certification is required for full benefits (see "Schedule of Benefits and Coverage"

section of this brochure). Preferred providers are listed on the HNL website at www.healthnet.com or you can

contact the Customer Contact Center at the telephone number listed on the back cover to obtain a copy of the

Preferred Provider Directory at no cost.

WHEN YOU USE AN OUT-OF-NETWORK PROVIDER, BENEFITS ARE SUBSTANTIALLY

REDUCED AND YOU WILL INCUR A SIGNIFICANTLY HIGHER OUT-OF-POCKET EXPENSE.

TO MAXIMIZE THE BENEFITS RECEIVED UNDER THIS HEALTH NET PPO INSURANCE

PLAN, YOU MUST USE PREFERRED PROVIDERS.

HOW TO ENROLL

Complete the enrollment form found in the enrollment packet and return the form to your employer. If a form

is not included, your employer may require you to use an electronic enrollment form or an interactive voice

response enrollment system. Please contact your employer for more information.

Some hospitals and other providers do not provide one or more of the following services that may be

covered under the plan's Certificate and that you or your dependents might need:

Family planning;

Contraceptive services; including emergency contraception;

Sterilization, including tubal ligation at the time of labor;

Infertility treatments; or

Abortion.

You should obtain more information before you enroll. Call your prospective doctor, participating or

preferred provider or clinic, or call the Customer Contact Center at the telephone number listed on the

back cover to ensure that you can obtain the health care services that you need.

4 PPO SB

Schedule of Benefits and Coverage The services covered and amount you pay depend upon the doctor or hospital you choose when you need

health care. The following charts summarize what is covered and what you pay with Health Net Life PPO.

Principal benefits and coverage matrix

Benefit Levels PPO OON (out-of-network)

Features (Preferred providers)

Care provided by doctors

and hospitals contracted with

our PPO

(All other providers) Care provided by licensed doctors and hospitals not contracted with our PPO 2

Lower out-of-pocket costs

Great freedom of choice

Certification from Health

Net Life required for

certain services

Claim forms usually not

required for

reimbursement

Must meet annual

deductible (and

coinsurance, if applicable

to this insurance plan)

Coverage for preventive

care services available

Higher out-of-pocket costs

Greatest freedom of choice

Certification from Health

Net Life required for

certain services

Claim forms required for

reimbursement

Must meet annual

deductible and coinsurance

For the PPO level of benefits, the percentages that appear in this chart are based on contracted rates

with providers. See the "Payment of Premiums and Charges" section, under "Contracted Rate" for

additional details.

For the out-of-network level of benefits, the percentages that appear in this chart are based the maximum

allowable amount. The covered person is responsible for charges in excess of this amount in addition to

the coinsurance shown. See the "Payment of Premiums and Charges" section, under "Maximum

Allowable Amount" for additional details.

PPO SB 5

Deductibles PPO OON (out-of-network)

You must pay this amount for covered services before HNL begins to pay. However, PPO services to

which a copayment applies are not subject to the calendar year deductible.

Any amount applied toward the deductible for covered services provided by a PPO provider will

apply toward the OON deductible; any amount applied toward the deductible for covered services

provided by an OON provider will apply to the PPO deductible.

Calendar year deductible

You must pay a deductible before the insurance plan begins to pay for covered services. Once

an individual member of a family satisfies the individual deductible, the remaining enrolled

family members must continue to pay a deductible until each enrolled family member

individually meets the individual deductible or the total amount paid by the family reaches the

family deductible.

For each covered person ............................... $250 .................................................. $500

For a family ................................................... $750 .................................................. $1500

Additional deductibles

Infertility services deductible (per

lifetime) ................................................... $500 .................................................. $500

Emergency room deductible

(waived if admitted to a hospital)

(per visit) ................................................... $100 .................................................. $100

Urgent care center deductible

(waived if admitted to a hospital) .............. $100 .................................................. $100

Combined for PPO and out-of-network.

Insurance Plan Maximums PPO OON (out-of-network)

Yearly Out-of-pocket maximum

(OOPM) for medical benefits

Once your payment of copayments or coinsurance (combined for PPO and out-of-network) for the

medical benefits equals the amount shown below in any one calendar year, no additional copayments

or coinsurance for covered services are required for the remainder of that year. Payments for services

not covered by this insurance plan, or for certain services as specified in the "Payment of Premiums

and Charges" section of this SB, will not be applied to this yearly out-of-pocket maximum. You will

need to continue making payments for any additional benefits as described in the "Additional

Insurance Plan Benefit Information" section of this SB.

For each covered person ............................... $3000 ................................................ $9000

For a family ................................................... $9000 ................................................ $27000

6 PPO SB

Yearly Out-of-pocket maximum

(OOPM) for prescription drug

benefits

Once your payment of copayments or coinsurance (combined for PPO and out-of-network) for the

prescription drug benefits equals the amount shown below in any one calendar year, no additional

copayments or coinsurance for covered prescription drugs are required for the remainder of that year.

Payments for services not covered by this insurance plan, or for certain services as specified in the

"Payment of premiums and charges" section of this SB, will not be applied to this yearly out-of-pocket

maximum.

For each covered person, for

Prescription Drugs ..................................... $2000 ................................................ $2000

For a family, for Prescription Drugs ............. $4000 ................................................ $4000

Type of services, benefit maximums & what you pay

Professional services

PPO OON

Office visit ........................................................... $15 .......................................................... 40%

Annual routine physical exam.............................. $15 .......................................................... Not covered

Calendar year maximum .................................. $250 ........................................................ Not applicable

Specialist consultations ........................................ $15 .......................................................... 40%

Physician visit to hospital or skilled

nursing facility .................................................. 20% ......................................................... 40%

Surgeon or assistant surgeon services, ............. 20% ......................................................... 40%

Administration of anesthetics .............................. 20% ......................................................... 40%

Rehabilitation therapy ....................................... 20% ......................................................... 40%

Maximum visits per calendar year, ............. 20 ............................................................ 20

Chemotherapy ...................................................... 20% ......................................................... 40%

Radiation therapy .............................................. 20% ......................................................... 40%

Teladoc consultation telehealth

services ......................................................... Covered in full ........................................ Not covered


These services require certification for coverage. For a complete listing of services

requiring certification please refer to the "Services Requiring Certification" section of this

SB. Routine care for condition of pregnancy does not require prior certification. However

notification of pregnancy is requested. If certification is required but not obtained, your

benefit reimbursement level will be reduced, both in-network and out-of-network, to 50% of

covered expenses. In addition, a $250 penalty will also be charged for inpatient admissions

and a $50 penalty for outpatient visits.

** Health Net Life contracts with Teladoc to provide telehealth services for medical, mental disorders

and chemical dependency conditions. Teladoc services are not intended to replace services from

your physician, but are a supplemental service. Teladoc consultations provide primary care services

by telephone or secure online video. Teladoc physicians may be used when your physician’s office is

closed or you need quick access to a physician. Teladoc consultation services may be obtained by

calling 1-800-TELADOC (800-835-2362) or visiting www.teladoc.com/hn. Before Teladoc services

may be accessed, you must complete a Medical History Disclosure (MHD) form, which can be

PPO SB 7

completed online at Teladoc’s website at no charge or printed, completed and mailed or faxed to

Teladoc. Surgery includes surgical reconstruction of a breast incident to mastectomy, including

surgery to restore symmetry; also includes prosthesis and treatment of physical

complications at all stages of mastectomy, including lymphedema.

Benefits for up to 12 additional visits are payable if precertified as medically necessary

following neurological and orthopedic surgery, cerebral cardiovascular accident, third

degree burns, head trauma or spinal cord injuries. All visit maximums will be combined for

covered services and supplies provided by preferred providers and out-of-network

providers. Medically Necessary rehabilitative services following post-mastectomy

lymphedema syndrome are not subject to such visit limitations* In addition, medically

necessary rehabilitative or habilitative services for autism or pervasive developmental

disorder are not subject to such visit limitations.

* The coverage described above in relation to Medically Necessary rehabilitative services for

post-mastectomy lymphedema syndrome complies with requirements under the Women's

Health and Cancer Rights Act of 1998. In compliance with the Women’s Health Cancer

Rights Act of 1998, this Plan provides benefits for mastectomy-related services, including all

stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses,

and complications resulting from a mastectomy, including lymphedema.

Outpatient Services

PPO OON

Outpatient facility services (other than

surgery, except for infertility

services) .......................................................... 20% ......................................................... 40%

Outpatient surgery (hospital or

outpatient surgery center charges

only, except for infertility

services) ......................................................... 20% ......................................................... 40%



SB. If certification is required but not obtained, your benefit reimbursement level will be

reduced, both in-network and out-of-network, to 50% of covered expenses. In addition, a

$250 penalty will also be charged for inpatient admissions and a $50 penalty for outpatient

visits.

Outpatient care for infertility is described below in the "Infertility Services" section.

Hospital Services PPO

OON

Semi-private hospital room or special

care unit with ancillary services,

including delivery and maternity care

(unlimited days) ............................................. 20% ......................................................... 40%

Skilled nursing facility stay ............................... 20% ......................................................... 40%

Maximum days per calendar year .................. 100 .......................................................... 100

Confinement for bariatric (weight loss)

surgery .............................................................. 20% ......................................................... 40%

8 PPO SB






visits.


The above coinsurance for inpatient hospital or special care unit services is applicable for each admission

for the hospitalization of an adult, pediatric or newborn patient. If a newborn patient requires admission to a

special care unit, a separate coinsurance for inpatient hospital services for the newborn patient will apply.

Inpatient care for infertility is described below in the "Infertility Services" section.

Radiological Services PPO

OON

Laboratory procedures and diagnostic

imaging (including x-ray) ................................. 20% ......................................................... 40%

These services require certification for coverage. For a complete listing of services requiring

certification please refer to the "Services Requiring Certification" section of this SB. If

certification is required but not obtained, your benefit reimbursement level will be reduced,

both in-network and out-of-network, to 50% of covered expenses. In addition, a $250

penalty will also be charged for inpatient admissions and a $50 penalty for outpatient visits.

Preventive Care PPO

OON

Preventive care services ...................................... Covered in full ........................................ Not covered

Preventive care services are covered for children and adults, as directed by your physician, based on the

guidelines from the U.S. Preventive Services Task Force Grade A&B recommendations, the Advisory

Committee on Immunization Practices that have been adopted by the Center for Disease Control and

Prevention, the guidelines for infants, children, adolescents and women’s preventive health care as

supported by the Health Resources and Services Administration (HRSA).

Preventive care services include, but are not limited to, periodic health evaluations, immunizations,

diagnostic preventive procedures, including preventive care services for pregnancy, and preventive

vision and hearing screening examinations, female sterilization, a human papillomavirus (HPV)

screening test that is approved by the federal Food and Drug Administration (FDA), and the option of

any cervical cancer screening test approved by the FDA.

Prenatal, postnatal and newborn care that are preventive care are covered in full. If other non-

preventive services are received during the same office visit, the office visit copayment will apply for the

non-preventive services.

Breastfeeding support, supplies, including a breast pump, and counseling consistent with HRSA

Guidelines for Women’s Prevent Services.

Emergency Health Coverage PPO

OON

Emergency room (facility and

professional services) ....................................... 20% ......................................................... 20%

Urgent care center (facility and

professional services) ....................................... 20% ......................................................... 20%

PPO SB 9

The coinsurance shown for PPO emergency health care services will be applied for all emergency

care, regardless of whether or not the health care provider is a PPO or noncontracting provider. The

coinsurance shown for PPO and out-of-network providers are applicable only if non-emergency care is

provided at an emergency room or urgent care center.

Ambulance Services PPO

OON

Ground ambulance ............................................ 20% ......................................................... 40%

Air ambulance ................................................... 20% ......................................................... 40%






visits.

Outpatient Prescription Drug Plan

Prescription Drugs Participating Pharmacy Nonparticipating Pharmacy

Please refer to the "Prescription Drug Program" section of this SB for definitions,

benefits and limitations.

Retail Pharmacy (up to a 30-day supply)

Tier 1 drugs .......................................................... $10 .......................................................... $10 plus 50%

Tier 2 drugs ........................................................ $25 .......................................................... $25 plus 50%

Tier 3 drugs ........................................................ $35 .......................................................... $35 plus 50%

Preventive drugs, including smoking

cessation drugs, and women’s

contraceptives * ................................................ Covered in full ........................................ Not covered

Specialty Pharmacy Vendor (up to a 30-day supply)

Specialty Pharmacy

Except as listed below, all Specialty Drugs are subject to the applicable Tier 1, 2 or 3 drug copayments

shown above under the retail pharmacy.

Self-injectable drugs and drugs for the

treatment of hemophilia, including

blood factors ...................................................................................................................... $15

Mail-Order Program (up to a 90-day supply of maintenance drugs)

Tier 1 drugs .......................................................... $20 .......................................................... Not covered

Tier 2 drugs ........................................................ $50 .......................................................... Not covered

Tier 3 drugs ........................................................ $70 .......................................................... Not covered

10 PPO SB

Preventive drugs, including smoking

cessation drugs, and women’s

contraceptives* ................................................. Covered in full ........................................ Not covered

Orally administered anti-cancer drugs will have a copayment and coinsurance maximum of $200 for an

individual prescription of up to a 30-day supply.

All other Prescription Drugs will have a Copayment and Coinsurance maximum of $250 for an individual

prescription of up to a 30-day supply.

Generic drugs will be dispensed when a generic drug equivalent is commercially available. When a brand

name drug is dispensed and a generic equivalent is commercially available, the covered person must pay

the difference between the generic equivalent and the brand name drug in addition to the listed copayments

or coinsurance.

However, if the prescription drug order indicates "dispense as written," "do not substitute" or words of

similar meaning, only the listed drug copayment will be applicable.

* Preventive drugs, including smoking cessation drugs and women’s contraceptives that are approved by the

Food and Drug Administration, are covered at no cost to the covered person. Preventive drugs are

prescribed over-the-counter drugs or Prescription Drugs that are used for preventive health purposes per

the U.S. Preventive Services Task Force A and B recommendations.

If a brand name drug is dispensed, and there is a generic equivalent commercially available, you will be

required to pay the difference in cost between the generic and brand name drug. However, if a brand name

drug is medically necessary and the physician obtains prior authorization from Health Net Life, then the

brand name drug will be dispensed at no charge.

Up to a 12-consecutive-calendar-month supply of covered FDA-approved, self-administered hormonal

contraceptives may be dispensed with a single prescription drug order.

Medical Supplies PPO

OON

Durable medical equipment .............................. 20% ......................................................... 40%

Diabetes education ............................................... 20% ......................................................... 40%

Orthotics (such as bracing, supports and

casts) .............................................................. 20% ......................................................... 40%

Corrective footwear ........................................... 20% ......................................................... 40%

Diabetic equipment .............................................. 20% ......................................................... 40%

Diabetic footwear ................................................ 20% ......................................................... 40%

Prostheses .......................................................... 20% ......................................................... 40%

Durable medical equipment is covered when medically necessary and acquired or supplied by an HNL

designated contracted vendor for durable medical equipment. Preferred providers that are not

designated by HNL as a contracted vendor for durable medical equipment are considered out-of-

network providers for purposes of determining coverage and benefits. For information about HNL's

designated contracted vendors for durable medical equipment, please contact the Customer Contact

Center at the telephone number on the back cover.

PPO SB 11

See also the "Prescription Drug Program" section of this SB/DF for diabetic supplies benefit

information. Diabetic equipment covered under the medical benefit (through "Diabetic equipment")

includes blood glucose monitors designed for the visually impaired, insulin pumps and related supplies,

and corrective footwear. Diabetic equipment and supplies covered under the prescription drug benefit

include insulin, specific brands of blood glucose monitors and testing strips, Ketone urine testing strips,

lancets and lancet puncture devices, specific brands of pen delivery systems for the administration of

insulin (including pen needles) and insulin syringes.

In addition, the following supplies are covered under the medical benefit as specified: visual aids

(excluding eyewear) to assist the visually impaired with the proper dosing of insulin are provided

through the prosthesis benefit; Glucagon is provided through the self-injectable benefit. Self-

management training, education and medical nutrition therapy will be covered only when provided by

licensed health care professionals with expertise in the management or treatment of diabetes (provided

through the patient education benefit).

These services require certification for coverage. For a complete listing of services requiring certification

please refer to the "Services Requiring Certification" section of this SB. If certification is required but not

obtained, your benefit reimbursement level will be reduced, both in-network and out-of-network, to 50% of

covered expenses. In addition, a $250 penalty will also be charged for inpatient admissions and a $50

penalty for outpatient visits.

Mental Disorders and Chemical

Dependency Benefits

PPO OON

Severe mental illness includes schizophrenia, schizoaffective disorder, bipolar disorder (manic-

depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorders,

pervasive developmental disorder (including Autistic Disorder, Rett's Disorder, Childhood

Disintegrative Disorder, Asperger's Disorder and Pervasive Developmental Disorder not otherwise

specified to include Atypical Autism, in accordance with the most recent edition the Diagnostic and

Statistical Manual for Mental Disorders), autism, anorexia nervosa and bulimia nervosa.

Serious emotional disturbances of a child is when a child under the age of 18 has one or more mental

disorders identified in the most recent edition of the Diagnostic and Statistical Manual of Mental

Disorders, other than a primary chemical dependency disorder or developmental disorder, that result in

behavior inappropriate to the child's age according to expected developmental norms. In addition, the

child must meet one of the following: (a) as a result of the mental disorder, the child has substantial

impairment in at least two of the following areas: self-care, school functioning, family relationships or

ability to function in the community; and either (i) the child is at risk of removal from home or has

already been removed from the home or (ii) the mental disorder and impairments have been present for

more than six months or are likely to continue for more than one year; (b) the child displays one of the

following: psychotic features, risk of suicide or risk of violence due to a mental disorder; and/or (c) the

child meets special education eligibility requirements under Chapter 26.5 (commencing with Section

7570) of Division 7 of Title 1 of the Government Code.

Mental Disorder and Chemical Dependency benefits are administered by MHN Services, an affiliate

behavioral health administrative services company, which contracts with HNL to administer these

benefits.

Outpatient office visits ....................................... $15 .......................................................... 40%

Outpatient services other than office

visits ............................................................... Covered in full ........................................ 40%

12 PPO SB

Inpatient facility (including

detoxification) ................................................ 20% ......................................................... 40%





$250 penalty will also be charged for inpatient admissions.

Services include psychological evaluation or therapeutic session in an office setting, medication management

and drug therapy monitoring.

Services include psychological and neuropsychological testing, other outpatient procedures, intensive

outpatient care program, day treatment, partial hospitalization and other outpatient services.

Home Health Services PPO

OON

Home health visits ................................................ 20% ......................................................... 40%

Maximum visits per calendar year ................. 100 .......................................................... 100


Other Services PPO

OON

Blood, blood plasma, blood derivatives

(except for drugs used to treat

hemophilia, including blood factors) ........... 20% ......................................................... 20%

Renal dialysis ....................................................... 20% ......................................................... 40%

Hospice services ................................................ 20% ......................................................... 40%

Infusion therapy (home or physician's

office) ............................................................ 20% ......................................................... 40%

Number of days for each supply of

injectable prescription drugs and

other substances, for each delivery .................. 14 ............................................................ 14






visits.

Drugs used to treat hemophilia, including blood factors, are covered under the pharmacy

benefit. Specialty drugs are not covered under the medical benefit even if they are

administered in a physician’s office. If You need to have the provider administer the

specialty drug, You will need to obtain the specialty drug through the Specialty Pharmacy

Vendor and bring it with you to the provider’s office. Alternatively, you may be able to

coordinate delivery of the specialty drug directly to the provider’s office through the

Specialty Pharmacy Vendor.

Infertility Services

PPO OON

Infertility services and supplies (all

covered services that diagnose,

evaluate or treat infertility) ............................... 20% ......................................................... 40%

PPO SB 13

Lifetime benefit maximum (applies to

all covered infertility services,

including oral infertility drugs) ..................... $2000 ...................................................... $2000


Notes:

Infertility services include prescription drugs, professional services, inpatient and outpatient care and

treatment by injections.

All calculations of the lifetime benefit maximum for Infertility services for each covered person are based on

the total aggregate amount of benefits paid under this plan and all other Health Net or HNL plans sponsored

by the same employer.

Chiropractic Care PPO

OON

Office visits .......................................................... $15 .......................................................... 40%

Maximum visits per calendar year ................. 20 ............................................................ 20

Maximum amount payable by HNL

per visit ............................................................. No maximum ........................................... $25


Acupuncture Care PPO

OON

Office visits .......................................................... $15 .......................................................... 40%

Maximum visits per calendar year ................. 20 ............................................................ 20


14 PPO SB

Limits of Coverage WHAT’S NOT COVERED (EXCLUSIONS AND LIMITATIONS)

Air or ground ambulance and paramedic services that are not emergency care or which do not result in a

patient's transportation will not be covered unless certification is obtained and services are medically

necessary.

Care for mental health care as a condition of parole or probation, or court-ordered treatment and testing

for mental disorders, except when such services are medically necessary;

Charges in excess of rate negotiated between any organization and the physician, hospital or other

provider;

Conception by medical procedures (IVF and ZIFT);

Conditions resulting from the release of nuclear energy when government funds are available;

Corrective footwear is not covered unless medically necessary and custom made for the covered person or

is a podiatric device to prevent or treat diabetes-related complications;

Cosmetic services or supplies;

Custodial or live-in care;

Dental services. However, medically necessary dental or orthodontic services that are an integral part of

reconstructive surgery for cleft palate procedures are covered. Cleft palate includes cleft palate, cleft lip

or other craniofacial anomalies associated with cleft palate;

Disposable supplies for home use;

Experimental or investigational procedures, except as set out under the "Clinical Trials" and "If You Have

a Disagreement with Our Insurance Plan" sections of this SB;

Genetic testing is not covered except when determined by Health Net Life to be medically necessary. The

prescribing physician must request prior authorization for coverage;

Hearing aids;

Hearing examination (age 17 and older);

Hypnosis;

Immunizations and injections for foreign travel or occupational purposes;

Marriage counseling, except when rendered in connection with services provided for a treatable mental

disorder;

Non-eligible institutions. This insurance plan only covers services or supplies provided by a legally

operated hospital, Medicare-approved skilled nursing facility or other properly licensed facility as

specified in the Certificate. Any institution, regardless of how it is designated, is not an eligible

institution. Services or supplies provided by such institutions are not covered;

Nontreatable disorders;

Orthoptics (eye exercises);

Orthotics (such as bracing, supports and casts) that are not custom made to fit the covered person's body.

Refer to the "corrective footwear" bullet above for additional foot orthotic limitations;

Outpatient prescriptions drugs or medications (except as noted under "Prescription Drug Program");

Personal or comfort items;

Physician self-treatment;

Physician treating immediate family members;

Private rooms when hospitalized, unless medically necessary;

Private-duty nursing;

Refractive eye surgery unless medically necessary, recommended by the covered person's treating

physician and authorized by Health Net Life;

Reversal of surgical sterilization;

Routine foot care for treatment of corns, calluses and cutting of nails, unless prescribed for the treatment

of diabetes;

PPO SB 15

Services and supplies determined not to be medically necessary as defined in the Certificate;

Services and supplies not specifically listed in the plan's Certificate as covered expenses;

Services and supplies that do not require payment in the absence of insurance;

Services for an injury incurred in the commission (or attempted commission) of a crime unless the

condition was an injury resulting from an act of domestic violence or an injury resulting from a medical

condition;

Services for conditions of pregnancy for a surrogate pregnancy are covered when the surrogate parent is

the covered person under this HNL plan. However, when compensation is obtained for the surrogacy,

Health Net Life shall have a lien on such compensation to recover its medical expense. A surrogate parent

is a woman who agrees to become pregnant with the intent of surrendering custody of the child to another

person;

Services not related to a covered illness or injury, except as provided under preventive care and annual

routine exams;

Services received before effective date or after termination of coverage, except as specifically stated in

the "Extension of Benefits" section of the plan's Certificate;

Services related to educational and professional purposes, except for behavioral health treatment for

pervasive developmental disorder or autism;

State hospital treatment, except as the result of an emergency or urgently needed care;

Stress, except when rendered in connection with services provided for a treatable mental disorder;

Treatment of jaw joint disorders or surgical procedures to reduce or realign the jaw, unless medically

necessary;

Treatment of obesity, weight reduction or weight management, except for treatment of morbid obesity;

Vision examination (age 17 and older).

The above is a partial list of the principal exclusions and limitations applicable to the medical portion of

your Health Net PPO insurance plan. The Certificate, which you will receive if you enroll in this

insurance plan, will contain the full list.

16 PPO SB

Benefits and Coverage WHAT YOU PAY FOR SERVICES

The "Schedule of Benefits and Coverage" section explains your coverage and payment for services. Please

take a moment to look it over.

With Health Net PPO, you are responsible for paying a portion of the costs for your care. The amount you pay

can vary from a flat amount to a significant percentage of the costs. It all depends on the doctor (and hospital)

you choose.

You must pay a deductible before the insurance plan begins to pay for covered services.

You pay less when you receive care from doctors contracted with our PPO, since they have agreed in

advance to provide services for a specific fee.

If you choose to receive care from out-of-network doctors and hospitals, you will be responsible for the

applicable out-of-network coinsurance, plus payment of any charges that are in excess of the covered

expenses as defined in the Certificate.

Exceptions: In the following circumstances, the in-network level of coverage applies and you will not be

responsible for any amounts in excess of the covered expenses:

o If we authorize medically necessary services through an out-of-network provider because such

services are not available through a preferred provider; or

o When non-emergent out-of-network services are received at an in-network health facility.

For further details and necessary requirements, see the Certificate.

For some services, certification is necessary to receive full benefits. Please see the "Services Requiring

Certification" section of this brochure for details.

To protect you from unusually high medical expenses, there is a maximum amount, or out-of-pocket

maximum, that you will be responsible for paying in any given year. Once you have paid this amount, the

insurance plan will pay 100% of covered expenses. (There are exceptions, see the Certificate for details.)

SPECIAL ENROLLMENT RIGHTS IF YOU LOSE ELIGIBILITY FROM A MEDI-CAL PLAN

If you become ineligible and lose coverage under r a Medi-Cal plan, you are eligible for a special enrollment

period in which you and your dependent(s) are eligible to request enrollment in this plan within 60 days of

becoming ineligible and losing coverage from a Medi-Cal plan.

NOTICE OF REQUIRED COVERAGE

Benefits of this insurance plan provide coverage required by the Federal Newborns’ and Mothers’ Health

Protection Act of 1996 and Women’s Health and Cancer Right Act of 1998.

The Newborns’ and Mothers’ Health Protection Act of 1996 sets requirements for a minimum Hospital length

of stay following delivery. Specifically, Group health plans and health insurance issuers generally may not,

under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother

or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean

section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after

consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as

applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain

authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or

96 hours).

The Women’s Health and Cancer Right Act of 1998 applies to medically necessary mastectomies and requires

coverage for prosthetic devices and reconstructive surgery on either breast provided to restore and achieve

symmetry.

PPO SB 17

SERVICES REQUIRING CERTIFICATION1

The following services require certification for both PPO and OON coverage. If you do not contact Health Net

Life prior to receiving certain services, your benefit reimbursement level will be reduced as shown in the

"Schedule of Benefits and Coverage" section of this SB. A penalty will also be charged for uncertified

inpatient admissions, and a penalty will be charged for uncertified outpatient services as shown in the

“Schedule of Benefits and Coverage” section. These penalties do not apply to your out-of-pocket maximum.

(Note: after the OOPM has been reached if certification is not obtained, benefits for service(s) will not be paid

at 100%). Services provided as a result of an emergency do not require certification.

Services that require certification include:

Inpatient admissions

Any type of facility, including but not limited to:

Acute rehabilitation center

Chemical Dependency facility, except in an emergency

Hospice

Hospital, except in an emergency

Mental health facility, except in an emergency

Skilled Nursing Facility

Outpatient procedures, services or equipment

Ambulance: Non-emergency air or ground ambulance services

Capsule endoscopy

Clinical trials

Custom orthotics

Dermatology such as chemical exfoliation and electrolysis, dermabrasions and chemical peels, laser

treatment or skin injections and implants

Diagnostic Procedures:

o Advanced imaging

CT (Computerized Tomography)

CTA (Computed Tomography Angiography)

MRA (Magnetic Resonance Angiography)

MRI (Magnetic Resonance Imaging)

PET (Positron Emission Tomography)

o Cardiac imaging

Coronary Computed Tomography Angiography (CCTA)

Echocardiography

Myocardial Perfusion Imaging (MPI)

Multigated Acquisition (MUGA) scan

Durable Medical Equipment

18 PPO SB

o Bilevel positive airway pressure (BiPAP)

o Bone growth stimulator

o Continuous positive airway pressure (CPAP)

o Custom-made items, including custom wheelchairs

o Hospital beds and mattresses

o Power wheelchairs and accessories

o Scooters

o Ventilators

Enhanced External Counterpulsation (EECP)

Experimental/Investigational services

Genetic testing

Implantable infusion pumps including insertion or removal

Injections for intended use of steroid and/or pain management including epidural, nerve, nerve root, facet

joint, trigger point and Sacroiliac (SI) joint injection

Occupational therapy (includes home setting), subject to any benefit maximums stated in the "Schedule of

Benefits and Coverage" section, except when therapy is used to treat autism

Organ, tissue and stem cell transplant services, including pre-evaluation and pre-treatment services and the

transplant procedure

Outpatient pharmaceuticals:

o Most self-injectables, excluding insulin, require prior authorization. Please refer to the Formulary to

identify which drugs require Prior Authorization.

o All hemophilia factors and intravenous immunoglobulin (IVIG) through the Outpatient Prescription

Drug benefit require Prior Authorization and must be obtained through the Specialty Pharmacy

Vendor.

o Certain physician-administered drugs require prior authorization, including newly approved drugs,

whether administered in a physician office, free-standing infusion center, home infusion, ambulatory

surgery center, outpatient dialysis center, or outpatient hospital. Refer to the Health Net Life website,

www.healthnet.com, for a list of physician-administered drugs that require Certification for medical

necessity review or to coordinate delivery through our contracted Specialty Pharmacy Vendor.

o Most specialty drugs must have Prior Authorization through the Outpatient Prescription Drug benefit

and may need to be dispensed through the Specialty Pharmacy Vendor. Please refer to the Formulary

to identify which drugs require Prior Authorization. Urgent or emergent drugs that are medically

necessary to begin immediately may be obtained at a retail pharmacy.

o Other outpatient prescription drugs, as indicated in the Formulary, may require Prior Authorization.

Refer to the Formulary to identify which drugs require Prior Authorization.

Outpatient surgical procedures:

o Ablative techniques for treating Barrett’s esophagus and for treatment of primary and metastatic liver

malignancies

o Balloon sinuplasty

o Bariatric procedures

http://www.healthnet.com/

PPO SB 19

o Cochlear implants

o Joint surgeries

o Neuro or spinal cord stimulator

o Orthognathic procedures (includes TMJ treatment)

o Spinal surgery including, but not limited to, laminotomy, fusion, discectomy, vertebroplasty,

nucleoplasty, stabilization and X-Stop

o Uvulopalatopharyngoplasty (UPPP) and laser-assisted UPPP

o Vestibuloplasty

Physical therapy (includes home setting), subject to any benefit limitations stated in the "Schedule of

Benefits and Coverage" section, except when therapy is used to treat autism

Prosthesis and corrective appliances

Radiation therapy

Reconstructive and cosmetic surgery, service and supplies or procedures, including but not limited to:

o Bone alteration or reshaping such as osteoplasty

o Breast reductions and augmentations except when following a mastectomy (includes gynecomastia

and macromastia)

o Dental or orthodontic services that are an integral part of reconstructive surgery for cleft palate

procedures. Cleft palate includes cleft palate, cleft lip or other craniofacial anomalies associated with

cleft palate.

o Excision, excessive skin and subcutaneous tissue (including lipectomy and panniculectomy) of the

abdomen, thighs, hips, legs, buttocks, forearms, arms, hands, submental fat pad, and other areas

o Eye or brow procedures such as blepharoplasty, brow ptosis or canthoplasty

o Gynecologic or urology procedures such as clitoroplasty, labiaplasty, vaginal rejuvenation,

scrotoplasty, testicular prosthesis, vulvectomy

o Hair electrolysis, transplantation or laser removal

o Lift such as arm, body, face, neck, thigh

o Liposuction

o Nasal surgery such as rhinoplasty or septoplasty

o Otoplasty

o Treatment of varicose veins

o Vermilionectomy with mucosal advancement

Speech therapy (includes home setting), subject to any benefit maximums stated in the "Schedule of

Benefits and Coverage" section except when therapy is used to treat autism or gender dysphoria

1Certification is not required for the length of a hospital stay for reconstructive surgery incident to a

mastectomy (including lumpectomy) or for renal dialysis. Certification is also not required for the length of

stay for the first 48 hours following a normal delivery or 96 hours following cesarean delivery; however,

please notify HNL within 24 hours following birth or as soon as reasonable possible. No penalty will apply if

notification is not received.

20 PPO SB

COVERAGE FOR NEWBORNS

Children born after your date of enrollment are automatically covered at birth. To continue coverage, the child

must be enrolled through your employer before the 30th day of the child’s life. If the child is not enrolled

within 30 days of the child’s birth:

Coverage will end the 31st day after birth; and

You will have to pay for all medical care provided after the 31st day of your baby’s life.

EMERGENCIES

Health Net Life covers emergency and urgently needed care throughout the world. If you need emergency or

urgently needed care, seek care where it is immediately available.

You are encouraged to use appropriately the 911 emergency response system, in areas where the system is

established and operating, when you have an emergency medical condition (including severe mental illness

and serious emotional disturbances of a child) that requires an emergency response. All ambulance and

ambulance transport services provided as a result of a 911 call will be covered, if the request is made for an

emergency medical condition (including severe mental illness and serious emotional disturbances of a child).

If you go to an emergency facility for condition that is not of an urgent or emergency nature, it will be covered

at whichever level (PPO or OON) it qualifies for, subject to your insurance plans exclusions and limitations.

Emergency care means any otherwise covered service for an acute illness, a new injury or an unforeseen

deterioration or complication of an existing illness, injury or condition already known to the person or, if

a minor, to the minor’s parent or guardian that a reasonable person with an average knowledge of health

and medicine (a prudent layperson) would believe requires immediate treatment (including severe mental

illness and serious emotional disturbances of a child), and without immediate treatment, any of the

following would occur: (a) his or her health would be put in serious danger (and in the case of a

pregnant woman, would put the health of her unborn child in serious danger); (b) his or her bodily

functions, organs or parts would become seriously damaged; or (c) his or her bodily organs or parts

would seriously malfunction. Emergency care also includes treatment of severe pain or active labor.

Active labor means labor at the time that either of the following would occur: (a) there is inadequate time

to affect safe transfer to another hospital prior to delivery; or (b) a transfer poses a threat to the health

and safety of the covered person or her unborn child.

Urgently Needed Care means any otherwise covered medical service that a reasonable person with an

average knowledge of health and medicine would seek for treatment of an injury, unexpected illness or

complication of an existing condition, including pregnancy, to prevent the serious deterioration of his or

her health, but which does not qualify as Emergency Care, as defined in this section. This may include

services for which a person should reasonably have known an emergency did not exist.

MEDICALLY NECESSARY CARE

All services that are medically necessary will be covered by your Health Net Life insurance plan (unless

specifically excluded under the insurance plan). All covered services or supplies are listed in the plan's

Certificate; any other services or supplies are not covered.

PPO SB 21

CLINICAL TRIALS

Routine patient care costs for patients diagnosed with cancer or other life-threatening disease or condition who

are accepted into phase I, II, III, or IV clinical trials are covered when medically necessary, either

recommended by the covered person's treating physician or the covered person provides medical and scientific

information establishing eligibility for the trial, and authorized by Health Net Life. For further information,

please refer to the plan's Certificate.

CONTINUITY OF CARE

If our contract with a PPO health care provider is terminated, you may be able to elect continued care by that

provider if you are receiving care for an acute condition, serious chronic condition, pregnancy, new born,

terminal illness or scheduled surgery. If you would like more information on how to request continued care,

please call the Customer Contact Center at the telephone number listed on the back cover.

EXTENSION OF BENEFITS

If you or a covered dependent is totally disabled when your employer ends its agreement with Health Net Life,

we will cover the treatment for the disability until one of the following occurs:

A maximum of 12 consecutive months elapses from the termination date;

Available benefits are exhausted;

The disability ends; or

You become enrolled in another insurance plan that covers the disability.

Your application for an extension of benefits for disability must be made to Health Net Life within 90 days

after your employer ends its agreement with us. We will require medical proof of the total disability at

specified intervals.

OUT-OF-STATE PROVIDERS

Health Net PPO allows covered persons access to participating providers outside their state of residence. These

providers participate in a network, other than the HNL PPO network, that agrees to provide discounted health

care services to HNL covered persons. This program is through the out-of-state provider network shown on

your HNL ID card and is limited to covered persons traveling outside their state of residence.

If you are traveling outside your state of residence, require medical care or treatment, and use a provider from

the out-of-state provider network, your out-of-pocket expenses may be lower than those incurred when you use

an out-of-network provider.

When you obtain services outside your state of residence through the out-of-state provider network, you will

be subject to the same copayments, coinsurances, deductibles, maximums and limitations as you would be if

you obtained services from a preferred provider in your state of residence. There is the following exception:

covered expenses will be calculated based on the lower of (i) the actual billed charges or (ii) the charge that the

out-of-state provider network is allowed to charge, based on the contract between HNL and the network. In a

small number of states, local statutes may dictate a different basis for calculating your covered expenses.

CONFIDENTIALITY AND RELEASE OF COVERED PERSON INFORMATION

Health Net Life knows that personal information in your medical records is private. Therefore, we protect your

personal health information in all setting (including oral, written and electronic information). The only time we

22 PPO SB

would release your confidential information without your authorization is for payment, treatment, health care

operations (including but not limited to utilization management, quality improvement, disease or case

management programs) or when permitted or required to do so by law, such as for a court order or subpoena.

We will not release your confidential claims details to your employer or their agent. Often, Health Net Life is

required to comply with aggregated measurement and data reporting requirements. In those cases, we protect

your privacy by not releasing any information that identifies our covered persons.

PRIVACY PRACTICES

Once you become a Health Net Life covered person, Health Net Life uses and discloses a covered person’s

protected health information and nonpublic personal financial information* for purposes of treatment,

payment, health care operations, and where permitted or required by law. Health Net Life provides covered

persons with a Notice of Privacy Practices that describes how it uses and discloses protected health

information; the individual’s rights to access, to request amendments, restrictions, and an accounting of

disclosures of protected health information; and the procedures for filing complaints. Health Net Life will

provide you the opportunity to approve or refuse the release of your information for non-routine releases such

as marketing. Health Net Life provides access to covered persons to inspect or obtain a copy of the covered

person’s protected health information in designated record sets maintained by Health Net Life. Health Net Life

protects oral, written and electronic information across the organization by using reasonable and appropriate

security safeguards. These safeguards include limiting access to an individual's protected health information to

only those who have a need to know in order to perform payment, treatment, health care operations or where

permitted or required by law. Health Net Life releases protected health information to insurance plan sponsors

for administration of self-funded plans but does not release protected health information to plan

sponsors/employers for insured products unless the plan sponsor is performing a payment or health care

operation function for the plan. Health Net Life's entire Notice of Privacy Practices can be found in the plan's

Certificate, at www.healthnet.com under "Privacy" or you may call the Customer Contact Center at the

telephone number listed on the back cover to obtain a copy.

* Nonpublic personal financial information includes personally identifiable financial information that you

provided to us to obtain health plan coverage or we obtained in providing benefits to you. Examples include

Social Security numbers, account balances and payment history. We do not disclose any nonpublic personal

information about you to anyone, except as permitted by law.

TECHNOLOGY ASSESSMENT

New technologies are those procedures, drugs or devices that have recently been developed for the treatment of

specific diseases or conditions, or are new applications of existing procedures, drugs or devices. New

technologies are investigational or experimental during various stages of clinical study as safety and

effectiveness are evaluated and the technology achieves acceptance into the medical standard of care. The

technologies may continue to be investigational or experimental if clinical study has not shown safety or

effectiveness or if they are not considered standard care by the appropriate medical specialty. Approved

technologies are integrated into Health Net Life benefits.

Health Net Life determines whether new technologies are medically appropriate, or investigational or

experimental, following extensive review of medical research by appropriately specialized physicians. Health

Net Life requests review of new technologies by an independent, expert medical reviewer in order to determine

medical appropriateness or investigational or experimental status of a technology or procedure.

The expert medical reviewer also advises Health Net Life when patients require quick determinations of

coverage, when there is no guiding principle for certain technologies, or when the complexity of a patient’s

medical condition requires expert evaluation. If Health Net Life denies, modifies or delays coverage for your

requested treatment on the basis that it is Experimental or Investigational, you may request an independent

PPO SB 23

medical review (IMR) of Health Net Life’s decision from the Department of Insurance. Please refer to the

“Independent Medical Review of Grievances Involving a Disputed Health Care Service” in the Certificate for

additional details.

Utilization Management Utilization management is an important component of health care management. Through the processes of prior

certification, concurrent and retrospective review and care management, we evaluate the services provided to

our covered persons to be sure they are medically necessary and appropriate for the setting and time. These

processes help to maintain Health Net Life's high quality medical management standards.

PRIOR CERTIFICATION

Certain proposed services may require an assessment prior to approval. Evidence-based criteria are used to

evaluate whether or not the procedure is medically necessary and planned for the appropriate setting (that is,

inpatient, outpatient surgery, etc.).

CONCURRENT REVIEW

This process continues to authorize inpatient and certain outpatient conditions on a concurrent basis while

following a covered person’s progress, such as during inpatient hospitalization or while receiving outpatient

home care services.

DISCHARGE PLANNING

This component of the concurrent review process ensures that planning is done for a covered person’s safe

discharge in conjunction with the physician’s discharge orders and to authorize post-hospital services when

needed.

RETROSPECTIVE REVIEW

This medical management process assesses the appropriateness of medical services on a case-by-case basis

after the services have been provided. It is usually performed on cases where prior certification was required

but not obtained.

CARE OF CASE MANAGEMENT

Nurse care managers provide assistance, education and guidance to covered persons (and their families)

through major acute and/or chronic long-term health problems. The care managers work closely with covered

persons, their physicians and community resources.

If you would like additional information regarding Health Net Life utilization management process, please call

the Customer Contact Center at the telephone number listed on the back cover.

Payment of Premiums and Charges YOUR COINSURANCE, COPAYMENT AND DEDUCTIBLES

The "Schedule of Benefits and Coverage" section explains your coverage and payment for services. Please

take a moment to look it over.

24 PPO SB

PREPAYMENT OF PREMIUMS

Your employer will pay Health Net Life your monthly premiums for you and all enrolled dependents. Check

with your employer regarding any share that you may be required to pay. If your share ever increases, your

employer will inform you in advance.

OTHER CHARGES

You are responsible for payment of your share of the cost of services covered by this insurance plan. Amounts

paid by you are called copayments, coinsurance or deductibles, which are described in the "Schedule of

Benefits and Coverage" section of this SB. Beyond these charges the remainder of the cost of covered services

will be paid by Health Net Life.

When the total amount of deductibles, copayments and coinsurance you pay equals the annual out-of-pocket

maximum amount shown in the "Schedule of Benefits and Coverage" section, you will not have to pay

additional copayments or coinsurance for the rest of the year for most services provided, unless your doctor

charges an amount that Health Net Life considers to be in excess of covered expenses. Additionally,

deductibles, coinsurance and copayments for any covered supplemental benefits purchased by your employer

will not be applied to the limit, as well as:

Charges applied to the infertility deductible;

Charges in excess of covered expenses;

Charges for services or supplies not covered by this insurance plan;

Services for which the covered person is required to pay a 50 percent coinsurance; and

Penalties paid for services for which certification was required but not obtained.

For further information please refer to the Certificate. Covered expenses for out-of-network providers are

based on the maximum allowable amount.

CONTRACTED RATE

The contracted rate is the rate that preferred providers are allowed to charge you, based on a contract between

Health Net Life and such provider. Covered expenses for services provided by a preferred provider will be

based on the contracted rate.

MAXIMUM ALLOWABLE AMOUNT (MAA)

The Maximum Allowable Amount (MAA) is the amount on which HNL bases its reimbursement for covered

services and supplies provided by an out-of-network provider, which may be less than the amount billed for

those services and supplies. HNL calculates maximum allowable amount as the lesser of the amount billed by

the out-of-network provider or the amount determined as set forth below. Maximum allowable amount is not

the amount that HNL pays for a covered service; the actual payment will be reduced by applicable

coinsurance, copayments, deductibles and other applicable amounts set forth in the Certificate. Please refer to

the insurance plan’s Certificate for additional information.

PPO SB 25

Maximum Allowable Amount for Covered Services and Supplies, excluding Emergency Care and

outpatient pharmaceuticals, received from an Out-of-Network Provider is a percentage of what Medicare

would pay, known as the Medicare Allowable Amount, as defined in this Certificate.

For illustration purposes only, Out-of-Network Provider: 70% HNL Payment / 30% Covered

Person Coinsurance:

Out-of-Network Provider’s billed charge for extended office visit $128.00

MAA allowable for extended office visit (example only; does not mean

that MAA always equals this amount) $102.40

Your Coinsurance is 30% of MAA: 30% x $102.40 (assumes

Deductible has already been satisfied) $30.72

You also are responsible for the difference between the billed charge ($128.00)

and the MAA amount ($102.40) $25.60

TOTAL AMOUNT OF $128.00 CHARGE THAT IS YOUR RESPONSIBILITY $56.32

The Maximum Allowable Amount for facility services, including but not limited to Hospital, Skilled

Nursing Facility, and Outpatient Surgery, is determined by applying 150% of the Medicare Allowable

Amount.

Maximum Allowable Amount for Physician and all other types of services and supplies is the lesser of the

billed charge or 100% of the Medicare Allowable Amount.

In the event there is no Medicare Allowable Amount for a billed service or supply code:

a. Maximum Allowable Amount for professional and ancillary services shall be 100% of FAIR

Health’s Medicare gapfilling methodology. Services or supplies not priced by gapfilling

methodology shall be the lesser of: (1) the average amount negotiated with Preferred Providers

within the geographic region for the same Covered Services or Supplies provided; (2) 50th

percentile of FAIR Health database of professional and ancillary services not included in FAIR

Health Medicare gapfilling methodology; (3) 100% of Medicare Allowable Amount for the same

Covered Services or Supplies under alternative billing codes published by Medicare; or (4) 50% of

the Out-of-Network Provider’s billed charges for Covered Services. A similar type of database or

valuation service will only be substituted if a named database or valuation services becomes

unavailable due to discontinuation by the vendor or contract termination.

b. Maximum Allowable Amount for facility services shall be the lesser of: (1) the average amount

negotiated with Preferred Providers within the geographic region for the same Covered Services or

Supplies provided; (2) 100% of the derived amount using a method developed by Data iSight for

facility services (a data service that applies a profit margin factor to the estimated costs of the

services rendered), or a similar type of database or valuation service, which will only be

substituted if a named database or valuation services becomes unavailable due to discontinuation

by the vendor or contract termination; (3) 150% of the Medicare Allowable Amount for the same

Covered Services or Supplies under alternative billing codes published by Medicare; or (4) 50% of

the Out-of-Network Provider’s billed charges for Covered Services.

c. Maximum Allowable Amount for Out-of-Network Emergency Care will be the greatest of: (1)

the median of the amounts negotiated with Preferred Providers for the emergency service

provided, excluding any in-network Copayment or Coinsurance; (2) the amount calculated using

the same method HNL generally uses to determine payments for Out-of-Network providers,

excluding any in-network Copayment or Coinsurance; or (3) the amount paid under Medicare Part

A or B, excluding any in-network Copayment or Coinsurance.

26 PPO SB

d. Maximum Allowable Amount for non-emergent services at an in-network (PPO network) health

facility, at which, or as a result of which, You receive non-emergent Covered Services by an

Out-of-Network Provider, the non-emergent services provided by the Out-of-Network Provider

will be payable at the greater of the average Contracted Rate or 125% of the amount Medicare

reimburses on a fee-for-service basis for the same or similar services in the general geographic

region in which the services were rendered unless otherwise agreed to by the noncontracting

individual health professional and HNL.

e. Maximum Allowable Amount for covered outpatient pharmaceuticals (including but not limited

to injectable medications) dispensed and administered to the patient, in an outpatient setting,

including, but not limited to, Physician office, outpatient Hospital facilities, and services in the

patient’s home, will be the lesser of billed charges or the Average Wholesale Price for the drug or

medication.

The Maximum Allowable Amount may also be subject to other limitations on Covered Expenses. See

“Schedule of Benefits,” “Plan Benefits” and “General Limitations and Exclusions” sections for specific benefit

limitations, maximums, pre-certification requirements and payment policies that limit the amount HNL pays

for certain Covered Services and Supplies. HNL uses available guidelines of Medicare and its contractors,

other governmental regulatory bodies and nationally recognized medical societies and organizations to assist in

its determination as to which services and procedures are eligible for reimbursement.

In addition to the above, from time to time, HNL also contracts with vendors that have contracted fee

arrangements with providers (“Third Party Networks”). In the event HNL contracts with a Third Party

Network that has a contract with the Out-of-Network Provider, HNL may, at its option, refer a claim for Out-

of-Network Services to a fee negotiation service to negotiate the Maximum Allowable Amount for the service

or supply provided directly with the Out-of-Network Provider. In either of these two circumstances, You will

not be responsible for the difference between the Maximum Allowable Amount and the billed charges. You

will be responsible for any applicable Deductible, Copayment and/or Coinsurance at the Out-of-Network level.

NOTE: HNL has the right to adjust, without notice, the Maximum Allowable Amount. Claims payment will be

determined according to the schedule in effect at the time the charges are incurred. Claims payment will also

never exceed the amount the Out-of-Network Provider charges for the service or supply. You should contact

the Customer Contact Center if You wish to confirm the Covered Expenses for any treatment or procedure

You are considering.

For more information on the determination of Maximum Allowable Amount, or for information,

services and tools to help You further understand Your potential financial responsibilities for Out-of-

Network Services and Supplies please log on to www.healthnet.com or contact HNL Customer Service at

the number on Your member identification card.

LIABILITY OF ENROLLEE FOR PAYMENT

If you receive health care services from doctors outside our network, covered services will be paid at the out-

of-network benefit level. You are responsible for any copayments, coinsurance amounts and amounts in excess

of the maximum allowable amount.

REIMBURSEMENT PROVISIONS

If you have out-of-pocket expenses for covered services, call the Customer Contact Center for a claim form

and instructions. You will be reimbursed for these expenses less any required copayment, coinsurance or

deductible.

Please contact the Customer Contact Center at the telephone number listed on the back cover to obtain claim

forms, and to find out whether you should send the completed form to your doctor, hospital or to Health Net

PPO SB 27

Life. Claims must be received by Health Net Life within one year of the date of service to be eligible for

reimbursement.

How to file a claim:

For medical services, please send a completed claim form to:

Health Net Commercial Claims

P.O. Box 9040

Farmington, MO 63640-9040

For mental health disorders and chemical dependency services, please send completed claim form to:

MHN Services

P.O. Box 14621

Lexington, KY 40512-4621

MHN Services will give you claim forms on request. For more information regarding claims for covered

Mental Disorders and Chemical Dependency Services, you may call MHN Services at 1-800-444-4281 or you

may write MHN Services at the address given immediately above.

For outpatient prescription drugs, please send a completed prescription drug claim form to:

Health Net

C/O Caremark

P.O. Box 52136

Phoenix, AZ 85072

Please call the Customer Contact Center at the telephone number listed on the back cover or visit our

website at www.healthnet.com to obtain a prescription drug claim form.

Claims for covered expenses filed more than 20 days from the date of service will not be paid unless you

can show that it was not reasonably possible to file your claim within that time limit and that you have

filed as soon as was reasonably possible.

Renewing, Continuing or Ending Coverage RENEWAL PROVISIONS

The contract between Health Net Life and your employer is usually renewed annually. If your contract is

amended or terminated, your employer will notify you in writing.

INDIVIDUAL CONTINUATION OF BENEFITS

Please examine your options carefully before declining coverage.

If your employment with your current employer ends, you and your covered dependents may qualify for

continued group coverage under:

28 PPO SB

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985). For most groups with 20 or more

employees, COBRA applies to employees and their eligible dependents, even if they live outside of

California. Please check with your group to determine if you and your covered dependents are eligible.

Cal-COBRA Continuation Coverage. If you have exhausted COBRA and you live in the United States,

you may be eligible for additional continuation coverage under state Cal-COBRA law. This coverage may

be available if you have exhausted federal COBRA coverage, have had less than 36 months of COBRA

coverage and you are not entitled to Medicare. If you are eligible, you have the opportunity to continue

group coverage under the Certificate through Cal-COBRA for up to 36 months from the date that federal

COBRA coverage began.

USERRA Coverage: Under a federal law known as the Uniformed Services Employment and

Reemployment Rights Act (USERRA), employers are required to provide employees who are absent from

employment to serve in the uniformed services and their dependents who would lose their group health

coverage the opportunity to elect continuation coverage for a period of up to 24 months. Please check with

your group to determine if you are eligible.

Also, you may be eligible for continued coverage for a disabling condition (for up to 12 months) if your

employer terminates its agreement with Health Net Life. Please refer to the "Extension of Benefits" section of

this SB for more information.

TERMINATION OF BENEFITS

Your coverage under this insurance plan ends when:

The agreement between the employer covered under this insurance plan and Health Net Life ends;

The employer covered under this insurance plan fails to pay premium charges; or

You no longer work for the employer covered under this insurance plan.

If the employer covered under this insurance plan does not pay appropriate premium charges, benefits will end

on the last day for which premium charges have been made, unless you are totally disabled and apply for an

extension of benefits for the disabling condition within 90 days.

PPO SB 29

If the person involved in any of the above activities is the enrolled employee, coverage under this insurance plan will end as well for any covered dependents.

If You Have a Disagreement with Our Insurance

Plan The California Department of Insurance (CDI) is responsible for regulating disability insurance carriers

(Health Net Life is a disability insurance carrier). The CDI has a toll-free telephone number (1-800-927-

HELP) to receive complaints about carriers.

If you have been unable to resolve a problem concerning your insurance coverage, after discussions with

Health Net Life Insurance Company, or its agent or other representative, you may contact:

California Department of Insurance

Office of the Ombudsman

300 South Spring Street

South Tower

Los Angeles, CA 90013

1-800-927-HELP or 1-800-927-4357

www.insurance.gov

GRIEVANCE AND APPEALS PROCESS

If you are dissatisfied with the quality of care that you have received or feel that you have been incorrectly

denied a service or claim, you may file a grievance or appeal. You must file your grievance or appeal with

HNL within 365 calendar days following the date of the incident or action that caused your grievance.

How to file a grievance or appeal:

You may call the telephone number listed on the back cover or submit the covered person grievance form

through the HNL website at www.healthnet.com.

You may also write to:

Health Net Life Insurance Company

P.O. Box 10348

Van Nuys, CA 91410-0348

If your concern involves the Mental Disorders and Chemical Dependency program, call MHN Services at

1-888-426-0030 or write to:

MHN Services

Attention: Appeals and Grievances

P.O. Box 10697

San Rafael, CA 94912

Please include all the information from your Health Net Life identification card as well as the details of your

concern or problem. For a grievance or appeal of our benefit determination, we shall notify you of our decision

in writing or electronically within the following time frames:

30 PPO SB

Urgent Care claims: As soon as possible, taking into account the medical exigencies, but not later than 72

hours from the time the initial request was received by HNL, until the close of the case with the covered

person.

Non-Urgent Care services that have not been rendered (pre-service claims): Within a reasonable period of

time appropriate to the medical circumstances, but not later than 30 days from the time the initial request was

received by HNL, until the close of the case with the covered person.

Non-Urgent Care services that have already been rendered (post-service claims): Within a reasonable

period of time, but not later than 60 days from the time the initial request was received by HNL, until the close

of the case with the covered person.

In addition, you can request an independent medical review of disputed health care services from the

Department of Insurance, if you believe that health care services eligible for coverage and payment under

the insurance plan was improperly denied, modified or delayed by Health Net Life or one of its

participating providers.

Also, if Health Net Life denies your appeal of a denial for lack of medical necessity, or denies or delays

coverage for requested treatment involving experimental or investigational drugs, devices, procedures or

therapies, you can request an independent medical review of Health Net Life’s decision from the

Department of Insurance if you meet the eligibility criteria set out in the Certificate.

ARBITRATION

If you are not satisfied with the result of the grievance hearing and appeals process, you may submit the

problem to binding arbitration. Health Net Life uses binding arbitration to settle disputes, including medical

malpractice. When you enroll in Health Net Life, you agree to submit any disputes to arbitration, in lieu of a

jury or court trial.

Additional Insurance Plan Benefit Information The following insurance plan benefits show benefits available with your insurance plan. For a more complete

description of copayments, and exclusions and limitations of service, please see your insurance plan’s

Certificate.

Prescription Drug Program Health Net Life is contracted with many major pharmacy chains, supermarket based pharmacies and

privately owned neighborhood pharmacies. For a complete and up-to-date list of participating pharmacies,

please visit our website at www.healthnet.com or call the Customer Contact Center at the telephone number

listed on the back cover.

PRESCRIPTIONS BY MAIL DRUG PROGRAM

If your prescription is for a maintenance medication (a drug that you will be taking for an extended period),

you have the option of filling it through our convenient Prescriptions by Mail Drug Program. This program

allows you to receive up to a 90-consecutive-calendar-day supply of maintenance medications. For

complete information, call the Customer Contact Center at the telephone number listed on the back cover.

PPO SB 31

Schedule II narcotic drugs (which are drugs that have a high abuse risk as classified by the Federal

Drug Enforcement Administration) are not covered through mail order. For further information, please

refer to the Certificate.

THE HEALTH NET FORMULARY

This insurance plan uses the Formulary. The Health Net Formulary is the approved list of medications

covered for illnesses and conditions. It was developed to identify the safest and most effective medications

for Health Net Life covered persons while attempting to maintain affordable pharmacy benefits.

We specifically suggest to all Health Net Life contracted participating providers and specialists that they

refer to this Formulary when choosing drugs for patients who are Health Net Life covered persons. When

your physician prescribes medications listed in the Formulary, it ensures that you are receiving a high

quality prescription medication that is also of high value.

The Formulary is updated regularly, based on input from the Health Net Pharmacy and Therapeutics (P&T)

Committee. The committee members are actively practicing physicians of various medical specialties and

clinical pharmacists. Voting members are recruited from participating physician groups throughout

California based on their experience, knowledge and expertise. In addition, the P&T Committee frequently

consults with other medical experts to provide additional input to the Committee. Updates to the Formulary

and drug usage guidelines are made as new clinical information and new drugs become available. In order

to keep the Formulary current, the P&T Committee evaluates clinical effectiveness, safety and overall value

through:

Medical and scientific publications;

Relevant utilization experience; and

Physician recommendations.

To obtain a copy of Health Net Life most current Formulary, please visit our web site at

www.healthnet.com under the pharmacy information, or call the Customer Contact Center at the telephone

number listed on the back cover.

WHAT IS "PRIOR AUTHORIZATION?"

Some drugs require prior authorization. This means that your doctor must contact Health Net Life in advance

to provide the medical reason for prescribing the medication.

How to request prior authorization:

Requests for prior authorization, including step therapy exceptions, may be submitted electronically or by

telephone (at the phone number shown on your HNL ID Card) or facsimile. Urgent requests from

physicians for authorization are processed, and prescribing providers notified of HNL’s determination,

as soon as possible, not to exceed 24 hours, after Health Net Life’s receipt of the request and any

additional information requested by Health Net Life that is reasonably necessary to make the

determination. Routine requests from physicians are processed, and prescribing providers notified of

HNL’s determination, in a timely fashion, not to exceed 2 business days, as appropriate and medically

necessary, for the nature of the covered person's condition after Health Net Life’s receipt of the

information reasonably necessary and requested by Health Net Life to make the determination. Upon

receiving your physician’s request for prior authorization, Health Net Life will evaluate the information

submitted and make a determination based on established clinical criteria for the particular medication.

http://www.healthnet.com/

32 PPO SB

If a drug is eliminated from the Formulary, HNL will continue to cover the drug for covered persons who

were taking the drug when it was eliminated, provided that the drug is appropriately prescribed and is

safe and effective for treating the covered person’s medical condition.

The criteria used for prior authorization are developed and based on input from the Health Net P&T

Committee as well as physician specialist experts. Your physician may contact Health Net Life to obtain

the usage guidelines for specific medications.

If authorization is denied by Health Net Life, you will receive written communication including the specific

reason for denial. If you disagree with the decision, you may appeal the decision.

The appeal may be submitted in writing, by telephone or through e-mail. We must receive the appeal within 60

days of the date of the denial notice. Please refer to the plan's Certificate for details regarding your right to

appeal.

To submit an appeal:

Call the Customer Contact Center at the telephone number listed on the back cover

Visit www.healthnet.com for information on e-mailing the Customer Contact Center; or

Write to: Health Net Life

Customer Contact Center

P.O. Box 9103

Van Nuys, CA 91409-9103

WHAT’S COVERED

Please refer to the "Schedule of Benefits and Coverage" section of this SB for the deductibles and

copayments.

This insurance plan covers the following:

Tier 1 drugs listed as Tier 1 on the Formulary that are not excluded from coverage (primarily generic);

Tier 2 drugs listed as Tier 2 on the Formulary that are not excluded from coverage (primarily brand name

and diabetic supplies, including insulin); and

Tier 3 drugs listed on the Formulary as Tier 3 or drugs that are not listed on the Formulary.

Preventive drugs and women’s contraceptives

Specialty Drugs

Specialty Drugs listed in the Health Net Formulary are covered when prior authorization is obtained from

HNL and the drugs are dispensed through HNL’s Specialty Pharmacy Vendor. These drugs include self-

administered injectable, drugs used to treat hemophilia, including blood factors, and other drugs that have

significantly higher cost than traditional pharmacy benefit drugs. Please note that needles and syringes

required to administer the self-injected medications are covered only when obtained through the Specialty

Pharmacy Vendor.

Self-administered injectable medications are defined as drugs that are:

1. Medically necessary

2. Administered by the patient or family member; either subcutaneously or intramuscularly

3. Deemed safe for self-administration as determined by Health Net’s Pharmacy and Therapeutics

Committee

PPO SB 33

4. Included in the Health Net Formulary

5. Shown on the Formulary as requiring prior authorization.

MORE INFORMATION ABOUT DRUGS THAT WE COVER

Prescription drug covered expenses are the lesser of Health Net Life’s contracted pharmacy rate or the

pharmacy’s retail price for covered prescription drugs;

If a prescription drug deductible (per covered person each calendar year) applies, you must pay this

amount for prescription drug covered expenses before Health Net Life begins to pay. Diabetic supplies,

preventive drugs and women’s contraceptives are not subject to the deductible. After the deductible is met

the copayments or coinsurance amounts apply;

Prescription drug refills are covered, up to a 30-consecutive-day supply per prescription at a Health Net

Life contracted pharmacy for one copayment;

If the pharmacy’s retail price is less than the applicable copayment, the covered person will only pay the

pharmacy’s retail price and it will accrue to the deductible and out-of-pocket maximum;

Mail order drugs are covered up to a 90-consecutive-calendar-day supply. When the retail pharmacy

copayment is a percentage, the mail order copayment is the same percentage of the cost to Health Net

Life as the retail pharmacy copayment;

Preventive drugs are prescribed over-the-counter drugs or prescription drugs that are used for preventive

health purposes per the U.S. Preventive Services Task Force A and B recommendations. Covered

contraceptives are all FDA-approved contraceptives for women that are either available over-the-counter

or are only available with a prescription. Vaginal, oral, transdermal and emergency contraceptives are

covered under this pharmacy benefit. IUDs, implantable and injectable contraceptives are covered (when

administered by a physician) under the medical benefit. Refer to the plan’s Certificate for more

information.

Diabetic supplies (blood glucose testing strips, lancets, needles and syringes) are packaged in 50, 100 or

200 unit packages. Packages cannot be "broken" (that is, opened in order to dispense the product in

quantities other than those packaged). When a prescription is dispensed, you will receive the size of

package and/or number of packages required for you to test the number of times your physician has

prescribed for a 30-day period. For more information about diabetic equipment and supplies, please see

the endnotes in the "Schedule of Benefits and Coverage" section of this SB.

WHAT’S NOT COVERED (EXCLUSIONS AND LIMITATIONS)

Services or supplies excluded under pharmacy services may be covered under the medical benefits

portion of your insurance plan. In addition to the exclusion and limitations listed below, prescription

drug benefits are subject to the insurance plan’s general exclusions and limitations. Consult your

insurance plan’s Certificate for more information.

Allergy serum. Allergy serum is covered as a medical benefit. See "allergy serum" benefit in the

"Schedule of benefits and coverage" for details;

Coverage for devices is limited to FDA approved vaginal contraceptive devices, peak flow meters, spacer

inhalers and diabetic supplies. No other devices are covered;

Drugs that are appetite suppressants or are indicated for and prescribed for body weight reduction;

Drugs or medicines administered by a physician or physician’s staff member;

Drugs prescribed to shorten the duration of the common cold;

Drugs (including self-injectable medications) prescribed for the treatment of sexual dysfunction are not

covered;

34 PPO SB

Drugs prescribed for a condition or treatment not covered by this insurance plan are not covered.

However, the insurance plan does cover drugs for medical conditions that result from nonroutine

complications of a noncovered service.

Drugs prescribed for routine dental treatment;

Drugs used for diagnostic purposes;

Experimental drugs (those that are labeled "Caution - Limited by Federal Law to investigational use

only"). If you are denied coverage of a drug because the drug is investigational or experimental you will

have a right to independent medical review. See "If You Have a Disagreement with Our Insurance Plan"

section of this SB for additional information;

Hypodermic needles or syringes, except for specific brands of disposable insulin needles and syringes and

specific brands of pen devices.

Medical equipment and supplies (including insulin), that are available without a prescription are covered

when prescribed by a physician for the management and treatment of diabetes, or for preventive purposes

in accordance with the U.S. Preventive Services Task Force A and B recommendations or for female

contraception as approved by the FDA. Any other nonprescription drug, medical equipment or supply that

can be purchased without a prescription drug order is not covered even if a physician writes a prescription

drug order for such drug, equipment or supply. However, if a higher dosage form of a prescription drug or

over-the counter (OTC) drug is only available by prescription, that higher dosage drug will be covered.

Prescription drugs prescribed by an unlicensed physician;

Replacement of lost, stolen or damaged medications, once you have taken possession of the drugs;

Services or supplies which are covered in full or for which you are not legally required to pay;

Supply amounts for prescriptions that exceed the FDA’s or Health Net Life’s indicated usage

recommendation are not covered unless Medically Necessary and prior authorization is obtained from

Health Net Life;

This is only a summary. Consult your insurance plan’s Certificate to determine the exact terms and

conditions of your coverage.

PPO SB 35

Nondiscrimination Notice

Health Net Life Insurance Company complies with applicable federal civil rights laws and does not

discriminate, exclude people or treat them differently on the basis of race, color, national origin, ancestry,

religion, marital status, gender, gender identity, sexual orientation, age, disability, or sex.

Health Net:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as

qualified sign language interpreters and written information in other formats (large print, accessible

electronic formats, other formats).

• Provides free language services to people whose primary language is not English, such as qualified

interpreters and information written in other languages.

If you need these services, contact Health Net’s Customer Contact Center at 1-800-522-0088 (TTY: 711)

If you believe that Health Net has failed to provide these services or discriminated in another way based on one

of the characteristics listed above, you can file a grievance by calling Health Net's Customer Contact Center at

the number above and telling them you need help filing a grievance. Health Net’s Customer Contact Center is

available to help you file a grievance. You can also file a grievance by mail, fax or online at:

Health Net Life Insurance Company Appeals & Grievances

PO Box 10348

Van Nuys, CA 91410-0348

Fax: 1-877-831-6019

Email: [email protected] (Covered Persons)

[email protected] (Applicants)

You may submit a complaint by calling the California Department of Insurance at:

1-800-927-4357 or online at https://www.insurance.ca.gov/01-consumers/101-help/index.cfm.

If you believe you have been discriminated against because of race, color, national origin, age, disability, or

sex, you can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office

for Civil Rights (OCR), electronically through the OCR Complaint Portal, at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201

1-800-368-1019, (TDD: 1-800-537-7697).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:[email protected]

mailto:[email protected]

Notice of Language Services

93547

CONTACT US

For more information, please contact us at:

Health Net PPO

Post Office Box 9103

Van Nuys, California 91409-9103

Customer Contact Center

1-800-522-0088 – California PPO Covered Person

1-800-331-1777 (Spanish)

1-877-891-9053 (Mandarin)

1-877-891-9050 (Cantonese)

1-877-339-8596 (Korean)

1-877-891-9051 (Tagalog)

1-877-339-8621 (Vietnamese)

Telecommunications Device

for the Hearing and Speech Impaired

1-800-995-0852

Online: www.healthnet.com Health Net of California, Inc. is a subsidiary of Health Net, LLC Health Net is a registered service mark of Health Net, LLC. All rights reserved.

summary of benefitsbenefitsm.filice.com/dominican/2020/hn_ppo_bensum.pdf · when you use an...

Documents